Patient Information - Dr. Arnold
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Driver's License#
Social Security Number
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AGE
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Patient Birth Date
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Ethnicity
*
Hispanic
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Race
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White
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Patient E-Mail
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Marital Status
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Name of Spouse
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Spouse SSN Last 4 Digits (####)
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Patient's Employer
*
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Employer Phone #
*
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Spouse's Employer
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Spouse Employer Phone #
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Responsible Party
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(if patient is a Minor) If patient is NOT a minor, enter NA.
Responsible Party Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
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Tunisia
Turkey
Turkmenistan
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Tuvalu
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Uruguay
Uzbekistan
Vanuatu
Vatican City
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Isle of Man
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Insurance - Primary
Subscriber Name
*
Subscriber Birth Date
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2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
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1979
1978
1977
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1975
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1973
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1969
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1950
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1948
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Insurance Company
*
ID #
*
Group Number
*
Insurance - Secondary
Subscriber Name
If none, please enter NA.
Insurance Company
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ID #
If none, please enter NA.
Group Number
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Emergency Contact & Pharmacy
Emergency Contact
*
Phone #
*
Pharmacy Location & Phone
CONSENT FOR TREATMENT:
*
I HEREBY CONSENT TO MEDICAL SERVICES AND TREATMENT RENDERED BY DR. DAVID ARNOLD AND TO THE RELEASE OF MEDIAL RECORDS TO AND FROM OTHER PROVIDERS RELATED TO THIS TREATMENT.
ASSIGNMENT OF INSURANCE BENEFITS:
*
I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS MY INSURANCE CLAIM. I AUTHORIZE PAYMENT DIRECTLY TO DR. DAVID ARNOLD. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS.
Authorized Name
*
First Name
Last Name
Today's Date
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Month
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Day
Year
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Medical History
Date of First Symptom
*
Referred By
*
Brief Summary of Today's Complaint
*
Do You or Have You Had Any of These Illnesses?
*
Yes
No
Diabetes
High Blood Pressure
Abnormal Bleeding
Lung Disease
Heart Disease
Digestive Tract Disease
Asthma/Emphysema
Cancer
Hepatitis
HIV Positive
Kidney Disease
Seizures/Strokes
Any Drug or Medication Allergies?
*
Yes
No
If Yes, Please Specify.
*
If none, please enter NA.
Are You Taking Cortisone or Prednisone?
*
Yes
No
Are You Taking Diet Pills?
*
Yes
No
Height
*
Weight
*
Do You Exercise Regularly?
*
Yes
No
Do You Smoke?
*
Yes
No
If Yes, How Much and How Long:
*
If No, enter NA.
Do You Vape or use E Cigarettes?
*
Yes
No
If Yes, How Much and How Long:
*
If No, enter NA.
Do You Drink Alcohol?
*
Yes
No
If Yes, How Much:
*
If No, enter NA.
Have you Ever Used Recreational Drugs?
*
Yes
No
Please Specify What and Last Day of Use:
*
If No, enter NA.
Have You Ever Had a Blood Transfusion?
*
Yes
No
When:
*
If No, enter NA.
Review of Systems
*
Yes
No
Fever
Weight Loss/Gain
Vision Problems
Hearing Problems
Mouth Sores
Neck Stiffness
Chest Pain
Cough
Shortness of Breath
Wheezing
Irregular Heart Beats
Diarrhea
Constipation
Blood in Stools
Difficulty Urinating
Vaginal Discharge
Swolen Lymph Glands
Difficulty Walking
Painful Joints
Jaundice
Skin Rash
Numbness Arms/Legs
Weakness Arms/Legs
Depression
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Medication, Surgical & Family History
Please list All Medications, including Strength and Dosage
*
Please list All Past Surgical Procedures, including Dates:
*
Has Any Family Member Been Treated for Heart Trouble, Diabetes, High Blood Pressure, Cancer or Bleeding Tendency. (i.e. Mother, Father, Sister, Brother, Grandparents, Aunts, Uncles, etc.)
*
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